Behavioral Health

Forms

You can use this form to give facts about a person's mental health background and needs to experts. The facts you provide help mental health, medical and law enforcement personnel provide the best care possible for your loved one.

Remember, we encourage you to discuss any complaints or issues about your Mental Health services with your Service Provider. You may file a Grievance by talking to your Service Provider, or to any Behavioral Health staff with whom you feel comfortable. Also, you have the choice of completing this form, or phoning in your Grievance to either of the following people:
Patients' Rights Advocate: 530-621- 6183 or 1-800-929-1955

You have 90 days to file this Appeal; the 90 days started the day after a Notice of Action was given or mailed to you. Remember, you need not have received a Notice of Action in order to file an Appeal. If you are unsure if this applies to you, you may ask any Behavioral Health staff member, or call one of the following numbers to request assistance:Problem Resolution Coordinator: 530-621-6290 or 1-800-929-1955Patient’s Rights Advocate: 530-621-6183

You may request a change of clinician, case manager, or doctor. While this is not always feasible, we will do our best to honor your request in a timely manner. To make such a request, please complete this form and give to the clinic receptionist, or you may return the form by mail.

This form may be given to mental health providers and hospitals. The mental health provider or hospital may have their own forms and require your family member to sign a new authorization for release of information.